451. THERE IS NO SUCH THING AS ‘DISEASES OF POVERTY’ THERE ARE ‘DISEASES OF WEALTH WITH INEQUALITY’.

We have to change our outlook, because, otherwise, those rendered poor appear as responsible of their ill-health. What the dominant public health model calls ‘diseases of poverty’ should actually be called ‘diseases generated by a social system that needs inequality to thrive’. Basically, no matter what others say, current public health does not really address the social context. (Jaime Breilh)

Making a diagnosis of the state of health is different from making a diagnosis of the situation of health

1. The UN special rapporteur for health has cautioned us that not all paths to universal health coverage (UHC) are consistent with human rights (HR) requirements; many of the paths being offered do not confer priority to those rendered poor and marginalized in the process of expanding health coverage. This, he suggests (and we know), gives rise to health strategies that prioritize improving access to health care for already more privileged groups especially those employed in the formal sector while some of the most vulnerable subgroups are left with health care that is abusive, coercive and/or of poor quality. (Dainius Puras)

2. Add to the above the fact that, as regards the future prospects of Comprehensive PHC, ‘cautious optimism’ is perhaps the right answer to the question: Is there a future for Comprehensive PHC? The answer being ‘yes’, requires considering the caveat that political commitment to health equity is requisite. …‘It is an idea too powerful to disappear.’ (Ron Labonte, David Sanders et al)

Human beings are not only targets of health programs nor are they beneficiaries of charitable largesse or of the application of expert knowledge. (Alicia Yamin)

3. Taking the right to health (RTH) seriously means accepting the narrative of health and health care being an asset of social citizenship. Taking HR seriously also requires ensuring that non-discrimination applies to the private sector as well (i.e., a person is legally entitled to use a health care provider, whether public or private, without facing discrimination). This means private providers cannot unilaterally terminate care. We are clear here: HR are not synonymous with or conditioned around specific goods, services or providers. Based on this, UHC, as we are seeing it implemented, may well ‘leave many behind’, as for example, the disabled, the mental health patients and LGBT persons. Achieving UHC will necessarily include legal enforcement, not just monitoring and actions within the health sector.* But while courts can play a positive role in checking arbitrariness, they cannot substitute for political action to ensure fair access to care.
*: ‘Anchoring Universal Health Coverage in the RTH: What difference would it make?’ See this excellent Policy Brief of WHO in 2015. It includes a good table on OPERA, the simple, yet comprehensive four-step framework to analyze various aspects of the obligation to fulfill economic and social rights. Adopting the acronym OPERA, the framework incorporates different measures for specific HR principles and standards. www.cesr.org/opera-framework

Has WHO become ‘A Pay to Play System’?

4. Having allowed corporate interests to direct its funding choices outside the ‘one country, one vote’ UN policy, WHO’s resolutions represent a growing ‘bilateralization’ of funding for what ought to be multilateral aid. There is growing urgent concern about WHO’s ability and commitment to provide an enabling environment for the RTH and sustainability to ensure that ‘crowding in’ corporate funding is not ‘crowding out’ publicly accountable governance. Many of WHO’s initiatives or partnership examples demonstrate new forms of public–private governance largely taking place outside UN mandates, yet waving the UN flag. (Barbara Adams) This is formidable opposition. Hereby, market power has already translated into political power. Let us face it: Few governments prioritize health over big business. This is not a failure of individual willpower. This is a failure of political determination to take-on big business. (paraphrasing Margaret Chan)

5. Democratizing WHO thus is about regaining public trust of the organization and its members so that they will value more and decisively act towards Health for All. The political-economic determinants that either undermine or promote progress towards this vision must be made explicit, and it is the critical constructive role of public interest civil society that will continue to be crucial in this. (People’s Health Movement) There is no time for contemplation anymore and we ought to move beyond soft diplomacy to further key RTH objectives. Bold, urgent, outspoken, pro-public and pro-planet public pronouncements are now (belatedly) required. (Medicus Mundi International)

Needed: Adopting a stand against the commercialization of healthcare

6. The contemporary narrative of social rights centers on individual rights. In the case of the RTH, these consist of legal entitlements to a minimum provision of medical treatment plus other core obligations such as food, freedom from hunger, basic shelter, sanitation, clean drinking water. All these can be made justiciable in courts of law. What most strikingly hinders the RTH is not a lack of this type of justiciability, but the failure to tackle the for-profit provision of healthcare that leads to unequal access on grounds of wealth or social privilege. The positive obligations of the RTH protect access to healthcare, not as an individual right, but as a public good. Protecting the RTH means to transform the provision of healthcare into a non-market area. By the same token, access to healthcare must be fulfilled by means of a public health service, free-of-charge for all. This does not mean that all healthcare needs will be served, or that difficult trade-offs will not occur. Yet, the fact that scarcity is not distributed on the basis of the individual’s lack of economic means, but on the grounds of either citizenship or medical need, leads to the distributive criteria that characterize HR under a regime of solidarity. In this light, the national healthcare service, as an institution organized around solidarity, is considered indispensable to the RTH. Individual justiciability is, therefore, not part of the core RTH provisions. In pursuing the goal of equal access to healthcare for all, solidarity means embarking on a relentless path towards the de-commodification of access to healthcare. (Eduardo Arenas Catalán)

7. Countries that protect a constitutional RTH perform better on key health indicators –and HIV is a key part of that story. Where rights are well enshrined and, most importantly, where rights-supporting organizations like Section 27 in South Africa, Kelin in Kenya, CEHURD in Uganda, and many more are well funded, there is a real opportunity. In these contexts, policy actors seeking to advance access and equity are better able to break into closed bureaucratic policy cycles and force issues ranging from how budgets are spent to which drugs are available to whom into the open. The most recent UNAIDS report focused on the RTH and with good reason. In 2018, HR have to move beyond first generation rights** and the important role they have played in protecting people from discrimination and avarice, as well as take the rights of access to services and medicines to scale –in the court rooms, yes, but more importantly outside, in all the venues where policy is made. (Matthew Cavanagh)
**: First-generation human rights deal essentially with liberty and participation in political life. They are fundamentally civil and political in nature: They serve negatively to protect the individual from excesses of the state. First-generation rights include, among other things, the right to life, equality before the law, freedom of speech, the right to a fair trial, freedom of religion, and voting rights. They were enshrined at the global level and given status in international law first by Articles 3 to 21 of the 1948 Universal Declaration of Human Rights and later in the 1966 International Covenant on Civil and Political Rights.

8. The RTH thus requires that the process for selecting and ranking health care criteria (not only about individual patients or treatments) be democratically legitimate, as well as scientifically sound; this challenges how priority setting has traditionally been done as a structurally technical exercise. (A. Yamin)

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CLAUDIO SCHUFTAN MD Saigon, Vietnam
Email: cschuftan@phmovement.org

Claudio Schuftan is a freelance public health consultant in Ho Chi Minh City and an ex-adjunct associate professor in the Department of International Health of the Tulane School of Public Health, USA. He is a Chilean national and got his M.D. degree in his native country.